This booklet is designed to be useful to senior medical officers filling billets for CATF Surgeons and Officers-in-Charge of Fleet Surgical Teams. The information herein is derived from primary sources that are usually identified within the text. Non-referenced information is included in order to tap the experience of previous CATF Surgeons, and is so identified.
Please send all correspondence concerning the content and style of this booklet to CAPT Jeffrey M. Young, MC, USNR, editor of the FMPR 1999, at the address below. All feedback is useful, and updates are scheduled for release annually.
Surface Warfare Medicine Institute
Building 500, Room 114
140 Sylvester Road
Naval Submarine Base
San Diego CA 92106-3521
Table of Contents Acronyms and Abbreviations 5
Blood Program 14
BUMED-14 Message 23
Casualty Receiving and Treatment Ships 24
CATF Surgeon Tasks 30
CLF Surgeon Tasks 32
Crisis Management 36
Echelons of Care 37
Fleet Surgical Teams 40
Liberty & Working Port Visits 61
Mass Casualties 63
Medical Intelligence 65
Message Writing 72
M+1 CRTS Wartime Manning 77
Post-deployment Critiques 79
Pre-deployment Checklist (BUMED) 83
Pre-deployment Checklist (PHIBGRU 3) 85
Preventive Medicine 89
Quality Assurance/Credentials 94
Ship’s Compartment Numbering 97
Shipboard Protocols 98
Shipboard Resources Guide 100
Shipboard Terminology 102
Victims & Perpetrators & Alcohol Misuse 113
WWW & Telephone List 114
ACKNOWLEDGEMENTS The following individuals were instrumental in the development of this reference. Their assistance has been invaluable and deeply appreciated.
CAPT John Fahey, MC, USN
CAPT Konrad Hayashi, MC, USN
CAPT Steve Nichols, MC, USN
CAPT T.G. Patel, MC, USN, Ret.
CAPT Terrence Riley, MC, USN
CAPT Adam Robinson, MC, USN
CAPT David Snyder, MC, USN
CAPT Michael Valdez, MC, USN
CAPT Jeffrey M. Young, MC, USNR
CDR Sue Herrold, NC, USN
CDR Doug McMullen, MC, USN
CDR Ken Schor, MC, USN
CDR Dave Taft, MC, USN
LCDR Dennis Moses, MSC, USN, Ret.
LCDR Eric Rasmussen, MC, USN
LCDR Sally Veasey, MSC, USN
LT Youssef H. Aboul-Enein, MSC, USNR
LT William Hatley, MSC, USN
LT Bruce Thompson, MSC, USN
Mr. Jeffrey Stiech, BUMED-14
ACRONYMS and ABBREVIATIONS
(NWP3, NWP4-02, JCS Pub 1, edited superset)
Composite Warfare Commanders
(Amphibious Ready Groups use an “L” designation instead of the leading “A”)
AA Officer in Tactical Command
AB Composite Warfare Commander
AQ Command and Control Warfare Commander
AW Anti-Air Warfare Commander
AS Anti-Surface Warfare Commander
AX Anti-Submarine Warfare Commander
AP Strike Warfare Commander
AR Air Resource Commander
Alphabetical Listing A
AAA arrival and assembly area
AAAV advanced amphibious assault vehicle
AABB American Association of Blood Banks
ABFC advance base functional components
ACE Air Combat Element
ACLS advanced cardiac life support
ACU Assault Craft Unit
ADAL Authorized Dental Allowance List
AECC aeromedical evacuation coordination center
AELT aeromedical evacuation liaison team
AFMIC Armed Forces Medical Intelligence Center
AJBPO area joint blood program office
ALCC airlift control center
AMMAL Authorized Minimum Medical Allowance List
AO area of operation; or Air Officer
AOR area of responsibility
ARG Amphibious Readiness Group
ASBBC Armed Services Blood Bank Center
ASBP Armed Services Blood Program
ASD (HA) Assistant Secretary of Defense (Health Affairs)
SORM Standard Organization and Regulations Manual of the US Navy (OPNAV 3120.32 series)
SORTS status of readiness and training
SPLT shore party liaison team
SPECAT special category
STANAG standardization agreement
STP Shock-trauma Platoon
SURGCO Surgical Company
T-AH hospital ship
TAML theater area (or Army) medical lab
T/O table of organization
TAC Tactical Air Commander
TACAN tactical air navigation system
TACC Tactical Air Control Center
TACLOG Tactical-Logistical Group
TACRON Tactical Air Control Squadron
TAD Tactical Air Director
TADC Tactical Air Direction Center
TAO Tactical Air Observer
TAOC Tactical Air Operations Center
TAR tactical air request (net circuit)
TEWA threat evaluation and weapons assignment
TF Task Force
TFMRS task force medical regulating system
TOC Tactical Operations Center
TOW tube-launched, optically-tracked, wire-guided (missile)
TPFDD time-phased force and deployment data
TPMRC Theater Patient Movement Requirements Center
TRAC2ES TRANSCOM's regulating command and control evacuation system
TRANSCOM Transportation Command
TRAP tactical recovery of aircraft and personnel
TYCOM Type Command
UDT Underwater Demolition Team
UNREP underway replenishment
USACOM United States Atlantic Command
USAF United States Air Force
VERTREP vertical replenishment
V/STOL vertical/short take-off and landing
WB whole blood
WIA wounded in action
WHO World Health Organization
WMCCS worldwide military and command control system
FLEET MEDICINE BIBLIOGRAPHY The following publications/references are for use in planning and delivery of fleet medical support. Most of these are directly referred to in NWP4.02, Operational Medical and Dental Support. Those with a double asterisk (**) have associated Medical Correspondence Courses available through the Naval School of Health Sciences, Portsmouth (www-nshspts.med.navy.mil/corres/courses.htm)
AFSC PUB 1
The Joint Staff Officer's Guide
BUMED INST 3400.1 Series
Operational Concept for Medical Support and Casualty Management in Chemical and Biological Warfare Environments
BUMED INST 5360.1 Series ** (NAVEDTRA 13154)
BUMED INST 5430.6 Series
BUMED Organization Manual
BUMED INST 6200 Series ** (NAVEDTRA 13112)
General Information on Preventive Medicine
BUMED INST 6300.2 Series
Medical Services and Outpatient Morbidity Reporting System
BUMED INST 6320.1 Series ** (NAVEDTRA 13113)
Medical Regulating To and Within the Continental United States
BUMED INST 6440.5 Series
Medical Augmentation Program
BUMED INST 6470.10
Initial Management of Irradiated or Radioactively Contaminated Personnel
BUMED INST 6700.13 Series
Authorized Medical / Dental Allowance List for U.S. Naval Vessels, Fleet Marine Force, and Other Elements of the Operating Forces
BUMED INST 6700.36 Series
Medical and Dental Equipment Maintenance and Repair Manual
CINCPACFLT/CINCLANTFLTINST 6400.1 Series
Mobile Medical Augmentation Readiness Team (MMART) Supply Block
DA Pamphlet 27-1
Treaties Governing Land Warfare (Geneva Conventions)
Defense Intelligence Agency Manual (DIA M) 59-1
Users Guide to Intelligence Dissemination / Reference Services
DOD 6420.1 Series
Organizational Functions of the Armed Forces Medical Intelligence Center
DOD 6480.4 Series
DOD Blood Program: Mobilization Planning Factors
FMFM 1-8 / NWP 3-02.1
Ship to Shore Movement
Combat Service Support
Medical and Dental Support, U.S. Marine Corps
Marine Corps Supplement to DOD Dictionary of Military and Associated Terms
Joint Pub 1-02
DOD Dictionary of Military and Associated Terms
Joint Pub 3-02
Joint Doctrine for Amphibious Operations
Joint Pub 4-02
Doctrine for HSS in Joint Operations
Joint Pub 4-02.1
JTTP for Health Service Logistics Support in Joint Operations
Joint Pub 4-02.2
JTTP for Patient Evacuation in Joint Operations
JOPES Volume I
Joint Operations Planning and Execution System, Medical Planning and Execution System (MEPES; formerly JOPS)
JOPS Volume I
Joint Operation Planning System, Volume I (Deliberate Planning Procedures)
JOPS Volume III
Joint Operation Planning System, Volume III (ADP Support), Appendix U (Medical Planning Module (MPM)
LFM 01 / NWP 22 / FM 31-11 / AFM 2-53
Doctrine for Amphibious Operations
MCO 6700.2 Series
Medical and Dental (Class VIII) Materiel for Support of the Fleet Marine Force
Logistic Reference Data
NAVMED P-117 (Available on Virtual Naval Hospital (VNH) website and VNH CD)
Manual of the Medical Department (MANMED)
Preventive Medicine Manual
The Treatment of Chemical Agent Casualties and Conventional Military Chemical Injuries
Medical Support in Joint Operations (1972)
Occupational and Environmental Health Prevention Treatment and Control of Heat Injury
The Radiation Health Protection Manual
Joint Blood Program Handbook, (ASBPO). January 1998
NAVMEDCOM INST S4812.1 Series
Bureau of Medicine and Surgery
NAVMEDCOM INST 6321.1 Series
Bed Capacity and Licensed Beds
NDP 1 ** (NAVEDTRA 13158)
NDP 2 ** (NAVEDTRA 13159)
NDP 4 ** (NAVEDTRA 13158)
NWP 5 ** (NAVEDTRA 13160)
NWP 6 ** (NAVEDTRA 13161)
Naval Command and Control
Naval Warfare Publication System
Naval Supplement to the DoD Dictionary of Military and Associated Terms
NWP 3-02.1 (Formerly NWP 22-3) / FMFM 1-8
Ship to Shore Movement
NWP 4-02 ** (NAVEDTRA 13158)
Operational Health Service Support
NWP 4-02.1 ** (NAVEDTRA 13158)
Health Service Support Logistics
Patient Movement, Part A: Naval Expeditionary Forces Medical Regulating
3. Echelon III: Ringers Lactate, albumin (25 percent), red blood cells (liquid and frozen), fresh frozen plasma, platelet concentrate
4. Echelon IV: Ringers Lactate, albumin (25 percent), red blood cells (liquid and frozen), fresh frozen plasma, platelet concentrate
Echelon V: Full range of resuscitation fluid and blood products
Planning Factors and Issues: (DoD INST 6480.4)
Four units of red blood cells per initial admission of each WIA and DNBI.
One technician and two cell washers can deglycerolize 48 units of frozen blood cells in 24 hours. Assign staff for 12-hour shifts and 7-day work weeks.
There is NO FROZEN BLOOD RESUPPLY TO SHIPS. Once frozen red cells are used by the LHDs, LHAs, and T-AHs, expect no additional frozen blood from the blood product depots (BPDs). Frozen blood is a transition into liquid blood; count on it for the first few days until the liquid blood pipeline is established. Hence, the early establishment of the pipeline of BSUs, BTCs, AJBPO, and JBPO is imperative.
Walking Blood Bank: This is a tertiary source of blood (i.e., to be used only after liquid and frozen blood sources have been depleted (CNSL/P 6000.1 series). However, walking blood bank response should be checked frequently. Activate the Walking Blood Bank (or parts of it) during mass-casualty drills.
EXTREMELY IMPORTANT: Meet OPNAV 6530.4A requirements: Save the donor card, a frozen plasma sample, and the correct donor / unit numbers. Report transfusions on ships to BUMED (code 273) for subsequent tracking in the future. This is a BIG ISSUE now, especially with HIV, HTLV, and hepatitis C.
Prior to deployment, acquire all message “go-bys” for bringing blood to the ship if needed (a task for the senior advanced lab tech).
BLOOD PROGRAM ACRONYMS AABB American Association of Blood Banks
AJBPO Area Joint Program Office (see JBPO, below), Component Command level.
ASBBC Armed Services Blood Bank Center. An armed service staffed blood bank with a Service assigned as executive agent, responsible for the collection, processing, and storage of blood products. The ASBBC provides blood products for medical treatment elements of two or more of the armed services.
ASBP Armed Services Blood Program
ASBPO Armed Services Blood Program Office
Tri-service staffed, joint field operating Agency, with Army as DoD Executive Agent. CONUS based. The overall DoD manager for blood and BP (class VIIIB) during military contingencies and, when directed, for civilian relief efforts.
ASWBPL Armed Services Whole Blood Processing Laboratory. Tri-service with USAF as Executive Agent. Shipment from CONUS blood banks to Unified Combat Command BTCs or TBTCs.
BDC Blood Donor Center. Component staffed. Requires FDA license.
BP Blood Products
BSU Blood Supply Unit. Component staffed. Receives BPs from BTCs and/or TBTCs or BPDs; issues those products to MTFs in assigned area.
BTC Blood Transshipment Center. USAF staffed. Middle man responsible to receiving, storing, re-icing, and shipping blood. See also TBTC (Transportable Blood Transshipment Center)
BPD Blood Product Depot. Component staffed. Strategic storage of frozen BP in a Unified Combatant Command. DoD Blood Program equivalent to Pre-Positioned Force.
JBPO Joint Blood Program Office. Tri-service staffed, overall joint BP management for Unified Combatant Commander. (cf: SBPO)
SBPO Service Blood Program Office. Component staffed, Coordination and management of that Service’s Blood Program.
TBTC See BTC above. USAF. Transportable to locations with minimal infrastructure.
Blood Support Activities Blood Resources Management and Support
Joint Blood Program Office - Each unified command has been requested by the Armed Services Blood Program Office to designate a joint health office to implement DoD blood program policies and coordinate the blood programs of the unified command components. The JBPO will be the single interface with the Armed Services Blood Program Office in CONUS. Normally, the JBPO will collocate with the Theater Patient Movement Requirement Center (TPMRC). The JBPO will redistribute blood among regions in the theater and will request blood supply from CONUS. The JPBO will submit a daily blood situation report to the Armed Services Blood Program Office during the contingency using the appropriate format (Annex A). Information copies will be provided to each AJBPO and other agencies as required.
Area Joint Blood Program Office - Unified commands have been requested by the Armed Services Blood Program Office to establish AJPBOs as required. They will implement the unified command blood program policies, coordinate the blood programs of the unified command components within their area, and manage blood products in the assigned BTC. Normally, the AJPBO will collocate with the Area TPMRC. The AJPBO will redistribute blood among components in the theater or request blood supply from the JBPO. The AJBPO will submit a daily blood situation report to the JPBO using the appropriate format (Annex A). Information copies will be provided to each component blood products depot unit and other agencies as appropriate.
Blood Transshipment Centers - The USAF operates the BTCs. The USAF is planning to staff and equip these centers to store and issue up to 3,000 units each of liquid and frozen blood products on a daily basis. Determining the numbers and locations of the centers is a responsibility of the unified command and will be adequate to support each unified command component’s blood requirements on an area basis. Normally, the Navy or Marine Corps will arrange transportation to obtain blood from the BTC for Navy or Marine Corps units. Blood issue to the Navy and Marine Corps will be based on a daily allocation system established by the theater JMBO. The allocations will be modified as required.
Frozen Blood Depots - The Navy operates one frozen blood depot in Sigonella, Sicily, and one in Okinawa, Japan. These depots have the capability to store 40,000 and 10,000 units of frozen blood, respectively. Each depot has one Medical Service Corps officer, Naval Officer Billet Code 0866; one enlisted technician, Navy Enlisted Classification 8506; and four civilian technicians, GS-644-04/05. These depots will provide frozen blood products to appropriate medical platforms upon direction by the AJBPO. The Army is also planning to establish frozen blood depots to store a total of 75,000 units of frozen blood products. The USAF is planning to store 50,000 units of frozen blood in Armed Services Whole Blood Processing Laboratories in CONUS.
Blood Supply Units - The Navy and Marine Corps will establish BSUs as recommended by the JBPOs. Personnel at these supply points will, upon direction by the AJBPO, arrange or provide transportation for blood products from the BTCs to the BSUs and then coordinate shipment to Navy or Marine Corps field medical units, Fleet Hospitals, and ships. The following units are likely to function as BSUs:
Frozen blood depots.
USMC units where medical personnel are responsible for coordinating blood and clinical fluids support.
FSSG detachments in the theater of operations.
Blood donor centers at Naples, Italy; Rota, Spain; and in the United Kingdom.
Medical Field Refrigerator - A lightweight, refrigerated blood box (NSN 410-01-287-7111) operating from direct or alternating current, containing 30 to 50 units of red blood cells. It has been shipped to the field medical supply activities by the Defense Personnel Support Center.
Frozen Blood Container - The USAF developed a shipping and storage container for frozen blood products to transport them without dry ice. It can be ordered through the local medical stock. The stock number is 814013571551 on the Management Data Listing.
Blood Box Management - Whenever possible, blood will be transported from blood supply points in boxes provided by the intended recipient. When the recipient has no box, attempt will be made to return boxes used to ship blood to the blood supply point or to exchange empty for full boxes.
Frozen Blood Management - Assure that Standard Operating Procedure (SOP) is clear on the new USAF frozen blood container and explains the proper handling of the eutectic solutions. To reuse the solutions, they must be COMPLETELY thawed to room temperature and then refrozen at –65C or lower.
Communications - All blood reports and blood shipment reports are sent using standard Armed Services Blood Program Office voice, message, and/or computer-generated blood report formats. The US Message Text Format is the basis for voice and message blood reports. The Armed Services Blood Program Office plans to have the Defense Systems Support Command automate the ASBP blood banks by developing the Defense Blood Standard System. The Theater Army Medical Management Information System has been designated to automate Army activities in the theater and modernized to support the Navy Fleet Hospitals as the Fleet Hospital blood bank module. Any computer systems purchased for CONUS blood collection stations will be compatible with the Defense Blood Standard System, and computer systems purchased for OCONUS MTFs shall be compatible with the Theater Army Medical Management Information System. The Armed Services Blood Program Office requires that the Theater Army Medical Management Information System and the Defense Blood Standard System also be compatible.
Walking Blood Bank - SOP will be clear that blood from walking donors is collected properly. OPNAV instruction require completion of donor cards, saving of frozen blood samples, and correct donor / unit numbers to identify the donor card, donor frozen sample, and unit number. This allows the donated units to be tested and “look-back” for HIV, HCV, etc., to be accurately accomplished.
Pre-qualifying walking donors in CONUS military blood banks just prior to deployment is a method used by some deploying units. However, regardless of pre-qualification, SOP must be followed for each donated unit.
BLOOD ISSUES ASHORE — LANDING FORCE
Echelon I, Unit Corpsman and Battalion Aid Station
Resuscitation fluids: Ringers Lactate, human albumin.
Blood / blood products: None.
Echelon II, Shock-trauma Platoons
Resuscitation fluids: Ringers Lactate, human albumin.
Blood / blood products: Frozen blood, Group O liquid blood
Echelon II, Surgical Company
Resuscitation fluids: Ringers Lactate, human albumin .
Blood / blood products: Liquid / frozen blood, fresh frozen plasma, platelet concentrate.
Operational Aspects - The CATF Surgeon or CLF Surgeon will assess blood resources / requirements daily and report to the AJBPO. The CATF Surgeon will coordinate blood and fluid support for the medical battalion from the CRTS, using medical field refrigerators and standard blood boxes. When the CRTSs leave the amphibious ops area, the medical battalion must rely on the medical logistics company or the AJBPO for blood. If no liquid blood is available, blood may be harvested from LF personnel or from the ship’s crew (before leaving the amphibious ops area).
Shock-Trauma Platoon - Each STP can draw 240 units of blood and can process and crossmatch 1,000 units. Each STP can store 120 units in field refrigerators. Occasionally, a STP may be augmented with a surgical support platoon, which has a blood bank capacity equivalent to that of a STP.
Amphibious Assault - Personnel responsible for management of clinical fluids and blood products will report to the CATF Surgeon or LF Surgeon daily. Consider locating a clinical fluids squad with the Surgical company and a clinical fluids platoon with the Medical Logistics Company. These squads can thaw and wash frozen blood and receive and distribute liquid blood. Submit daily blood reports to the AJBPO. The CRTS will supply thawed and washed using standard blood boxes and medical field refrigerators. Frozen blood will be transported in the new shipping and storage containers for frozen blood. Prior to the CRTS leaving the amphibious ops area, or the blood supply aboard the CRTS being depleted, the CLF Surgeon will request more blood / blood products from the AJBPO.
Surgical Company - If liquid or frozen blood is unavailable or unobtainable, each Surgical Company has the capability to draw 720 units and process and cross-match 3,000 units. Storage capability in current field refrigerators is 360 units.
Organizational Aspects - Resuscitation fluids and blood products transported ashore will be handled by the STP, the evacuation platoon at the Beach Evacuation Station, the helicopter support team evacuation station, and medical personnel charged with coordinating blood / clinical fluids for the Surgical or Medical Logistics Company. The CLF Surgeon or representative will manage blood resources and requirements. If frozen blood is needed on the beachhead, deglycerolize it on the LHA / LHD, then ship it ashore.
Transportation - Resuscitation fluids and blood products will be transported ashore primarily by helicopters dispatched to evacuate casualties. A secondary means is ground vehicle landing craft or amphibious landing craft. Transport of resuscitation fluids forward to regimental and BASs will be by any means available, depending heavily on vehicles used for medical evacuation. Additional delivery methods - Navy emergency air cargo delivery systems, low-altitude parachute extraction systems, and high-speed low-altitude - have been successfully tested and may be available. Blood products requested from and assigned by the AJBPO can be picked up or delivered by helicopter from the nearest BSU or BTC assigned by the AJBPO.
BLOOD ISSUES AFLOAT Echelon II
Resuscitation Fluids: Ringers Lactate, human albumin
Larger ships and CRTSs will possess the capability to process frozen blood products stored aboard those and other ships within the Task Force. For resupply, ships will contact the TF medical officer who will subsequently contact the AJBPO as needed. It is very important to identify blood resupply points during this communication. Smaller ships will rely on the larger ships and CRTS for blood support. Use the walking blood bank as a tertiary blood source when neither liquid red blood cells nor thawed and washed cells are available. Liquid blood will be transported to other ships in standard blood boxes with 14 lbs. of wet glistening ice or in medical field refrigerators. Frozen blood will be transported in the new shipping / storage container.
One technician with two cell washers can deglycerolize 48 units of frozen red blood cells in 24 hours, staffing based on 12-hour / 7-day work week. Blood aboard ship will be managed by embarked medical personnel and transported by supply and logistics personnel. The Task Force medical officer will manage blood resources and requirements.
Blood can be transported between ships by helicopter or high-line. Resupply of frozen or liquid blood from nearby blood supply points can be transported by helicopter. If distances are prohibitive, blood can be delivered by Navy emergency air cargo delivery system.
THE BUMED-14 MESSAGE
(Do Not Leave Homeport Without It)
LT Youssef H. Aboul-Enein, MSC, USNR
Mr. Jeffrey Stiech, BUMED 14
Every fiscal year BUMED-14 issues a message, Subj: FYXX CENTRALLY MANAGED ALLOTMENTS. This message contains accounting data that can be used for foreign hospitalizations, ambulance services, ancillary and non-medical attendant fees FOR ACTIVE DUTY ONLY. Use this message to pay all your foreign medical bills. The only requirement is that upon the completion of care you forward all copies of paperwork, medical records, and invoices to BUMED-14 (currently Mr. Jeff Stiech MED 14L, DSN 762-3577). This is important as it facilitates payment when the bill reaches DFAS (Defense Finance Accounting Service) and avoids embarrassment for your command.
DO NOT DEPLOY WITHOUT THIS MESSAGE. Two additional POCs are Dwight Daniels, (202) 762-3565, DSN 762-3565, and Perwez Hashmi, (202) 762-3578, DSN 762-3578.
Attention MRCOs: you may want to call Mr. Stiech to make sure your unit is an info addee to this valuable message.
CASUALTY RECEIVING & TREATMENT SHIPS
(NWP4-02, Section 5, edited subset)
Amphibious Task Force CRTSs
After troops debark for ship-to-shore movement, specific ships of the ATF are designated as primary CRTSs to provide Echelon II HSS to the landing force during amphibious operations. Primary CRTSs have laboratory (including blood) and radiology capability to support surgical suites. During amphibious ops, primary CRTSs are staffed as necessary to provide extensive trauma support. The ships normally designated as the primary CRTSs are the LHA, and LHD class amphibious assault ships.
The CATF may designate amphibious ships as secondary CRTSs. These may include any class ship with the capability to receive and treat casualties, if appropriate medical materiel and personnel are available to provide resuscitative care. Ships normally designated as secondary CRTSs include LPD, LSD, LKA, LST, and LCC class ships.